Regulatory Update
Oregon Hospice Association/Washington State
Hospice and Palliative Care Organization
Judi Lund Person, MPH
Vice President, Regulatory and Compliance
National Hospice and Palliative Care Organization
1
Recent regulatory updates
• Effective October 1, 2014 – implementation
of:
– NOE filing and penalty for non-compliance.
– NOTR filing.
– Change in attending physician form
• Effective March 31, 2015 – implementation
of Cap Self-Report to be sent to MAC
– If not filed, payments will be suspended
• Effective April 1, 2015 – CAHPS mandatory
participation for all hospice providers
2
What’s in the pipeline?
• Calendar year 2015
– Spring 2015: Announcement of Medicare Care
Choices Model awardees
– Spring 2015: FY 2016 Hospice Wage Index
Proposed rule
•
•
•
CBSA changes in wage index for hospice
Possible other regulatory changes
More Part D and hospice guidance
– October 1, 2015: ICD-10 implementation
3
UPDATE ON WASHINGTON
POLICY ACTIVITY
4
“Doc Fix”
• Sustainable Growth Rate (SGR)
• Possible permanent fix
• Possible one year adjustment in marketbasket
increase
• FY2018
• Latest information
5
MedPAC
• March 2015 Report to Congress just released
• Recommendations:
– Congress should eliminate the update to the
hospice payment rates for fiscal year 2016.
• Margins:
– Margins for all hospices in 2012: 10.1%
– Predicted margins for 2015: 6.6%
6
Number of Medicare Certified Hospices
4500
4000
3500
3000
2500
2000
1500
Number of
Hospices
1000
500
0
1985 1990 1996 1999 2003 2005 2007 2008 2009 2010 2011 2012 2013
Source: MedPAC March 2015 Report to Congress
7
Total Medicare Spending on Hospice
$15.1
15.1
2011
2012
Expenditures by Year
2013
16
Billions of Dollars
14
$13
$13.8
12
10
8
6
4
$2.9
2
0
2000
2010
Source: MedPAC March 2015 Report to Congress
Days of Care
Length of Service in Hospice
100
90
80
70
60
50
40
30
20
10
0
86 86 86 88 88
83
80
54
17 17 17 17 18 17 18 17
Average Length of Stay
2000
2007
2008
Source: MedPAC March Report to Congress, various years
2009
Median Length of Stay
2010
2011
2012
2013
MedPAC Reports on Levels of Care
10
Shifting from Diagnosis to
Prognosis
11
Statutory Definition of Terminally Ill
• Social Security Act - §1861(dd)(3)(A):
• Defines “terminally ill” as having a medical
prognosis that the individual’s life expectancy
is 6 months or less.
12
Diagnoses in perspective
Terminal
diagnosis
Any other diagnosis or
condition that is related
to the terminal
illness/prognosis
Related
diagnosis
or
condition
Primary or Principal diagnosis
Unrelated
diagnosis
Any other diagnosis that is not related
to the terminal illness/prognosis
13
Determining prognosis
• Hospice physicians determine prognosis from:
– Records review and lab reports
– IDG input
– Discussions with referral sources/attending
physicians
– Clinical judgment
– Examination of the patient (if applicable)
– Certification narrative is a good place to explain this
14
15
Physician Determines Relatedness
Clinical staff
collect
information
from patient
Hospice
physician
reviews all
available
information
Hospice
physician
confers with
attending
physician
and IDT
Decision Made
(subject to
revision as
patient
conditions
change)
• Relatedness is not determined by the CFO based on cost to hospice
provider
• It is determined patient by patient, case by case, related to the
palliative plan of care
15
16
If it is related to the terminal
prognosis.…
• Hospice covers the cost
– Care (services, treatment…)
– Medications
– DME & supplies
• Documentation should appear in the clinical
record that it is related
– Physician narrative
– Plan of Care
– Medication profile
16
Steps your hospice can take
• Evaluate admission process
• Ask the question “Does this diagnosis or condition
contribute to or influence the patient’s terminal
prognosis?”
• Review hospice physician documentation of
relatedness and unrelatedness
• Review medications for
– Related, hospice pays
– Unrelated
– Related but no longer effective, discontinue or patient
pays
• Check diagnosis reporting on claim form
17
NHPCO PROPOSALS TO CMS
18
Prognosis and
Parts A, B and D “Leakage”
• Addressing terminal prognosis
• Addressing improvements in systems and
practices for hospices
– NOE submission
– Improved care coordination functions
– Identification of physicians and other healthcare
providers actively involved in the patient’s care
• Issues for other providers
– Knowledge of the hospice election
– Access to Common Working File before claim is
submitted
19
Scope of Benefits and Services Waived
• Section 1812(d)(2) of the Social Security Act
establishes the scope of benefits and what the
patient waives by electing to receive hospice
care.
• The current language has not changed since
the Medicare hospice benefit was established
as a demonstration in 1983.
20
Waiver Language
• By electing to receive hospice care,
beneficiaries waive their right to have
payment made for:
“services that are determined (in accordance with
guidelines of the Secretary) to be related to the
treatment of the individual’s condition with respect
to which a diagnosis of terminal illness has been
made.”
21
NHPCO Relatedness Work Group
•
•
•
•
Meeting weekly for more than one year
A work group of the Regulatory Committee
Clinical expertise, including four physicians
Regulatory expertise for places where the
prognosis language may be appropriate
• HUGE discussions about approach
• HUGE discussions about clinical practice
• HUGE discussions about what makes sense for
patients and families
22
Basic Tenets of Relatedness
• Must be individualized and determined case-by- case
• Decisions must be made by hospice physician
• Based upon relationship to terminal prognosis and
related conditions
• Can be complex- how far down the chain of causality
do you go?
– Example: Diabetes and cardiac conditions; dialysis and
heart failure
23
Medical Director’s Key Role
• It is the role of the hospice medical director to
determine whether a diagnosis or medication is
related to the patient’s terminal illness and related
conditions
• The hospice must ensure that the hospice medical
director is involved, reviews medications, and
documents relatedness status in the medical record
24
Medical Directors’ Decisions
• Diagnoses
– Related or unrelated to the terminal prognosis
– Case-by-case
– Consistent reasoning that staff can understand and
communicate
• Medications
– Related, reasonable, and necessary
– Clinically useful
– Covered by hospice or insurance
25
Regulatory Committee
Recommendations
• Changes to CoPs and Interpretive Guidelines
• Suggestions for changes in hospice processes
as well as those of other Medicare providers
26
Changes to CoPs or Interpretive
Guidelines
– Appendix M is the hospice Appendix for “Surveyor
Guidance” used by surveyors in judging
compliance with the CoPs.
– Includes “Procedures and Probes” – questions
that the surveyor can ask hospice staff to assess
compliance with a Condition of Participation.
– Some, but not all recommended changes, will
require rule-making.
27
Focus Areas
• Comprehensive assessment
– Must reflect health status related and unrelated to terminal
prognosis
– Updates reflect changes and discontinuation of treatments and
medications
• Drug profile – include a list of all drugs, including those
unrelated to the terminal prognosis
• Plan of care – include care coordination with other
healthcare professionals actively involved in patient’s care
• Hospice medical director
– evidence of training in management of end of life care
– Responsible for determining related diagnoses, treatments and
medications
28
Proposed Process Changes for
Hospices
– Process changes for hospices
 Admissions
 Interdisciplinary team
o Coordination of care
o Initial and comprehensive assessment
o Medication review
– Comparing hospices to each other
– New and ongoing education about hospice
responsibilities for terminal prognosis
– Clear guidance about billing requirements
29
Proposed Changes for Other Medicare
Provider Types
• Provider knowledge of hospice election
• Hospital admission/discharge
• Flags in billing for other Medicare providers to
indicate hospice
election/revocation/discharge
• New and ongoing education for other provider
types about hospice
• Provide clear guidance on billing issues for
other provider types
30
Further Study
• Attending physician issues when the physician is
– A nursing home medical director
– A hospitalist identified by the hospital as the patient’s
attending
• Pre-hospice evaluation and goals of care
discussion
– Payment currently only for physicians
– Could it be expanded to other hospice clinicians or to
the hospice to avoid unnecessary hospitalizations
31
Ongoing Discussions
•
•
•
•
•
•
•
NOE
Prognosis/Relatedness
Cap self report and calculation re sequester
Program integrity
MAC medical review
Medicare Care Choices Model
Advance Care Planning
32
DIAGNOSES ON CLAIM FORM
33
Diagnoses on the claim form
• The principal diagnosis reported on the claim
is the diagnosis most contributory to the
terminal prognosis
• The hospice must report other diagnoses and
conditions that contribute to the patient’s
terminal prognosis as “other diagnoses”
• Follow coding conventions for ICD-9-CM and
then migrate to ICD-10-CM
34
Coding Reminders
• Certain dementia diagnoses may not be used
as a primary diagnosis – see NHPCO resources
• Alzheimer’s and dementia – still legitimate
hospice diagnoses
• Adult failure to thrive and debility unspecified
may not be used as a primary diagnosis
• Can be used as an other diagnosis
• Watch use of protein malnutrition as an
alternative
35
CMS Reports Multiple Diagnoses
on Claim
% of claims with one diagnosis
78
76
74
72
70
68
FY2010
77.2
66
Q1 - 10/1-10/31/12
72
64
FY2013
67
62
60
FY2010
36
Q1 - 10/110/31/12
FY2013
36
OFFICE OF INSPECTOR GENERAL
ACTIVITIES
37
Hospice care in assisted living
• Report released January 2015
• Payments in ALFs more than doubled in 5
years, totaling $2.1 billion in 2012.
• Hospice beneficiaries in ALFs often had
diagnoses that usually require less complex
care.
• Hospices typically provided fewer than 5 hours
of visits per week
• Visit mix was heavily hospice aides
38
Median Days in Hospice Care
by Beneficiary, by Setting
Median Days in Hospice Care
120
100
98
80
60
50
45
40
30
Days
20
0
ALF
Nursing Facility
Home
Skilled Nursing
Facility
Primary Setting of Hospice Care
39
Percentage of Beneficiaries with Long Lengths
of Stay, by Setting
40%
36%
Percentage of Beneficiaries
35%
30%
28%
25%
20%
22%
18%
181-365 days
14%
15%
> 365 days
10%
10%
5%
0%
ALF
Nursing Facility
Primary Setting of Hospice Care
Home
40
Medical Social
Service Visits,
0.3
Visits per Week, 2012
Hospice Aide
Visits, 2.4
Hospice Aide Visits
Nursing Visits
Medical Social Service Visits
Nursing Visits,
1.7
41
Percentage of Visit-Hours Provided to Beneficiaries Receiving
Routine Home Care in ALFs by Day of the Week, 2012
25%
20%
20%
19%
18%
18%
19%
15%
Visits
10%
5%
4%
3%
0%
Monday
Tuesda
Wednesday Thursday
Friday
Saturday
Sunday
42
OIG Areas of Concern
• 25 hospices reported no visits to their patients
in ALFs in 2012 -- $2.3 million in Medicare $$
• 97 hospices relied on ALFs for most of their
Medicare patients. More than ½ of Medicare
payments they received in 2012
43
OIG Recommendations
1. Reform payments to reduce the incentive for
hospices to target beneficiaries with certain
diagnoses and those likely to have long stays
2. Target certain hospices for review
3. Develop and adopt claims-based measures of
quality
4. Make hospice data publicly available for
beneficiaries
5. Provide additional information to hospices to
educate them about how they compare to their
peers.
44
Additional OIG Hospice Focus in 2015
• Review of Hospice GIP
– Assess the appropriateness of hospices’ general
inpatient care claims
– Review content of election statements for
hospice beneficiaries who receive general
inpatient care
– Review hospice medical records to address
concerns that this level of hospice care is being
misused or overused
45
KEY VULNERABILITIES
46
Key Vulnerabilities
• Live discharges
• General Inpatient Care, Continuous Care,
Inpatient Respite
• Non Hospice Spending In Medicare Parts A, B
And D: “Leakage”
• Visits in last 48 hours of life
47
LIVE DISCHARGES
48
Rates of Live Discharges
% of Patients
Discharged
Alive
0 – 9.9%
Number of
Hospices
10% - 19.9%
1,315
20% - 29.9%
371
30% - 39.9%
133
40% +
282
1,601
2010 Live Discharge
rates by state
• CT
• MS
12.8%
40.5%
Hospice claims data from CY 2010-CY 2012 for beneficiaries who were
discharged (alive or deceased) in CY 2012
49
Source: Journal of Palliative Medicine, August 7 2014
50
Live Discharge and Readmissions
Hospice
Discharge
Hospital
Admission
Expensive
test/procedure
$126 M
2010 Data
13,770 patients of
182,172 live
discharges – 7.5%
Hospice
Readmission
Hospital
Discharge
Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule
51
Live Discharge and Readmission by State
– Highest %
MS
VA
OK
TX
AL
NJ
SC
GA
MD
LA
$56.0 M (44%) of
the hospitalization
costs from these
10 states
CMS CY 2012; FY2015 Hospice Wage Index Final Rule
52
GENERAL INPATIENT CARE,
CONTINUOUS HOME CARE, AND
INPATIENT RESPITE CARE UTILIZATION
53
Percentage of days by level of care
Routine Home Care
Percentage of
Total Days
97.4%
Continuous Home Care
0.4%
Inpatient Respite Care
0.3%
General Inpatient Care
1.9%
Level of Care
54
GIP Utilization
• Patient utilization:
77.3% of patients electing hospice did not
have a GIP stay during their hospice election
• Hospices providing GIP
21.1% of hospices did not bill for a single day
of GIP in CY2012
Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule
55
GIP Utilization
• National average = 1.9%
of days are GIP
• Do not provide GIP?
– 66% for-profit
• Provide GIP?
– 5-10% = 195 hospices
– 10% or more = 46
hospices
Any GIP
Provided?
Number of
Hospices
No
760
Yes
2,758
Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012
56
Location of GIP
0.8
0.7
68.0%
0.6
0.5
Hospice Inpt Facility
0.4
Hospital
0.3
Skilled Nursing Facility
24.9%
Multi
0.2
0.1
5.5%
1.6%
0
% of Total
Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule
57
Length of GIP Stay by Location
7
6.1 days
6
5
5.5 days
4.5 days
4.7 days
All
4
Inpatient Hospice
3
Inpatient Hospital
SNF
2
1
0
Average Length of Stay in Days
Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule
58
Policy Questions
• Was the hospice able to provide GIP?
• Was the hospice “cherry picking” patients who
were “less sick?”
• Does the hospice comply with COP
requirement for a contract for GIP?
• Was quality of care compromised?
59
Non Hospice Spending In Medicare
Parts A, B And D: “Leakage”
60
Medicare A and B Outside Hospice Benefit
Part A or B Service
Percentage of $$
Spent
DME
7.1%
Inpatient care
28.6%
Outpatient Part B services
16.9%
Other Part B services (physician, practitioner,
labs and diagnostic tests, ambulance
transports, and physician office visits)
Skilled Nursing Facility Care
37.4%
Home Health Care
4.5%
5.7%
61
States where Medicare A and B Outside
the Hospice Benefit is Highest
WV
FL
TX
MS
SC
CMS CY 2012; FY2015 Hospice Wage Index Proposed Rule
62
Part D Expenditures During a
Hospice Stay
• CY2012
– Total Part D spending: $417.9 million
– Paid by Medicare: $334.9 million
63
Highest Part D Expenditures by State
ID
WV
AL
OK
CMS CY 2012; FY2015 Hospice Wage Index Final Rule
64
CY2012 Total Non-Hospice
Medicare Spending
For beneficiaries after hospice election
• Parts A & B: $710.1 million
• Part D: $334.9
• TOTAL: $1.3 Billion dollars
• Note: 51.6 % of $1.3 billion -- 373 hospices
• Average total per beneficiary: $1,289 in non-hospice
costs
65
VISITS IN LAST
48 HOURS OF LIFE
66
% of Patients with No Skilled Visits
Days before Death
% of Patients
Last day of life
28.9% of patients
Last 2 days of life
14.4% of patients
Last 3 days of life
9.1% of patients
Last 4 days of life
6.2% of patients
Skilled visits include nurse, social worker, therapies (OT, PT, Speech). Does not
include aide, chaplain, volunteer.
CMS CY 2012; FY2015 Hospice Wage Index Final Rule
67
Lowest % of Patients with No Visits in Last
2 Days of Life
State
% with
No Visits
WI
5.7%
ND
7.3%
VT
7.5%
TN
7.5%
KS
8.5%
CMS CY 2012; FY2015 Hospice Wage Index
Final Rule
68
Highest % of Patients with No Visits
in Last 2 Days of Life
State
% with
No
Visits
NJ
23%
MA
22.9%
OR
21.2%
WA
21%
MN
19.4%
CMS CY 2012; FY2015 Hospice Wage Index Final Rule
69
CMS Commentary
• We further examined hospice utilization data
and developed a provider-level file to identify
aberrant hospice behavior. The provider level
file contains information on beneficiaries who
were discharged (alive or deceased) in
Calendar Year (CY) 2012 and includes claims
data from January 1, 2010 through December
31, 2012.
70
HOSPICE PAYMENT REFORM
LATEST ABT INFORMATION
71
Recent CMS Statements
• Considering the analysis from Abt Associates
• Not likely to wait until data from the new
hospice cost report is in
• Still considering
– Rebasing (reducing) the routine home care rate
• Budget neutrality required
– U-shaped curve – or tiered payments
• Higher at the beginning (5 days being considered)
• Higher at the end
72
Abt Payment Reform Concepts
•
•
•
•
•
•
Site of service adjustment
Rebasing the routine home care rate
Tiered payment model
Short stay add-on
Skilled visits at the end of life
Live discharge
Abt presentation on Open Door Forum 1/14/15
73
Site of Service Adjustment
• Hospice patients in a nursing facility receive
more visits than patients in the home after
controlling for patient and provider
characteristics.
• Hospice aides may be substituting for, rather
than augmenting, nursing facility aides.
Abt presentation on Open Door Forum 1/14/15
74
Rebasing the Routine Home Care Rate
• Due to data limitations, only the labor portion
of the base payment rate could be rebased,
which represents approximately 70% of the
rate.
• Using just the labor information, it was found
that rebasing using current cost information
would result in a reduction in the FY 2014 RHC
payment rate of 10.1% ($1.6 billion).
Abt presentation on Open Door Forum 1/14/15
75
Tiered Payment Model
• Unintended Consequences of a simple UShaped Payment System
– Could encourage extremely short stays
– Could increase live discharges
– How would level of care transfers be handled (GIP
to RHC?)
– Could reduce frequency of services in response to
decreased reimbursement
Abt presentation on Open Door Forum 1/14/15
76
Tiered Payment Model
• Different payments for characteristics that
might be associated with the cost of the stay.
– Would have features of a U-Shaped Model.
– Could also pay for
• Extremely short stay hospice users (who tend to have
high average resource use)
• Hospice users who do not receive skilled care at the
end of life.
Abt presentation on Open Door Forum 1/14/15
77
Tiered Payment Model
Group
RHC Days
Days of
Hospice
Implied
Weight
New Base
Payment Rate
Group 1
RHC Days 1-5
2,800,144
2.3
$337.25
Group 2
RHC Days 6-10
2,493,004
1.11
$162.76
Group 3
RHC Days 11-30
7,767,918
0.97
$142.23
Group 4
RHC Days 31+
65,958,740 0.86
$126.10
Group 5
RHC during last 7 days, skilled
visits during last 2 days
2,832,620
2.44
$357.78
Group 6
RHC during last 7 days, NO skilled
visits during last 2 days
476,809
0.91
$133.43
Group 7
RHC when hospice LOS is 5 days or 510,787
less and discharged dead
3.64
$533.73
Total
82,840,022 1
Abt presentation on Open Door Forum 1/14/15
$146.63
78
Short Stay Add-on
• Background:
– Stays that are 5 days or less (25% of beneficiaries
in 2011) are less U-shaped because there is not a
lower cost middle period between the time of
admission and the time of death.
– A potential reform would be to only increase
payments for the shortest stays through an addon that would be paid for through a reduction to
payment for long stay beneficiaries
Abt presentation on Open Door Forum 1/14/15
79
Skilled visits at the end of life
• There is considerable variation in the
probability of receiving skilled visits at the end
of life that may be related to certain
characteristics of the hospice stay.
• These characteristics include
– The day of the week a beneficiary died
– Which state the beneficiary is located in
– Which specific hospice a beneficiary receives
services from
Abt presentation on Open Door Forum 1/14/15
80
CAP REPORTING
Cap self-report
PS&R
Inpatient cap
81
Cap Determination Notice
§ 418.308 Limitation on the amount of
hospice payments.
(c) The hospice must file its aggregate cap determination notice
with its Medicare contractor no later than 5 months after the end
of the cap year (that is, by March 31st)
• Use data no earlier than three months after the end of the
cap period, or January 31
• If hospice fails to file, payments will be suspended in whole
or in part until cap report is filed
• Overpayments will be due when cap report is filed. An
Extended Repayment Schedule (ERS) is available.
• The MAC will continue to issue final cap determination letter
82
2013 Cap Reports
• For 2013, cap letters will come from MACs
• Timing in question, could be up to one year
83
Inpatient days cap
& non-compliance risk
• MACs will continue to calculate the inpatient
days cap
• If hospice fails to file the aggregate cap report,
payments will be suspended in whole or in part until
cap report is filed
84
IMPACT ACT
Hospice Surveys
Medical Review
Hospice Aggregate Cap
85
IMPACT Act
• Stands for:
Improving Medicare Post-Acute Care Transformation
Act of 2014 (“IMPACT Act”)
• Impacts post acute providers including:
– home health agency
– skilled nursing facility
– inpatient rehabilitation facility
– long-term care hospital
86
Hospice Provisions in IMPACT Act
• Three provisions:
Hospice surveys every 36 months
• Implementation date: April 6, 2015
• Surveys conducted by state survey agency or
accrediting organization
• No change in process except frequency
• State determined implementation
• In place for the next 10 years
87
Hospice Provisions in IMPACT Act
Increased medical review for long lengths of stay
• Technical correction to the Affordable Care Act
• Intended for hospices who have a high percentage of
patients with a length of stay >180 days
• What is the “high percentage?”
– CMS will set the number – in the 40-60% range
• Implementation date: CMS can begin the process at
any time. CMS reports that they are gathering data on
the issue to make a decision
88
Hospice Provisions in IMPACT bill
Hospice aggregate cap
• Aligns the inflation increase for the aggregate cap and
the hospice rate increase
• Implementation date: FY2017 (Payment year
beginning October 1, 2016)
• Example of when cap amount and rates increase at
same rate:
Example
10/31/2014
Cap for year
ending October
31, 2014
$
26,725.79
Marketbasket
Increase
Example of Cap
Amount for
Coming Year
1.70%
$ 27,180.13
89
QUALITY REPORTING
90
Quality Reporting Reminders
• Hospice CAHPS survey:
– Every hospice must participate in at least a one
month dry run between January 1 and March 31
– Mandatory participation begins April 1
• HIS data submission:
– ended for 2014
– ongoing for 2015
91
Moving Hospice Upstream
Expanding the Use of Hospice Skills
within the Healthcare Continuum
November 2014
NHPCO Consulting Services
92
Hospice Use by Medicare Decedents,
2012
47%
Received hospice care
No hospice
53%
Source: A Data Book: Healthcare Spending and the Medicare Program, Medicare Payment Advisory Commission (MedPAC), June 2014, p. 187.
November 2014
NHPCO Consulting Services
93
Transferrable Hospice Skills
• Managing patients under a risk-based
payment method – controlling costs
• Managing patients with high needs and high
levels of frailty
• Managing patients with complex, lifethreatening illness
• Managing patients in a home or home-like
setting
• Managing patients out in the community
November 2014
NHPCO Consulting Services
94
Hospice Saves Medicare Significant
Costs
$7,000
$6,430
$6,000
$5,040
$5,000
$4,000
$3,000
$2,650
$2,561
$2,000
$1,000
$0
1-7 Days
8-14 Days
15-30 Days
53-105 Days
Source: Amy S. Kelley, et al., “Hospice Enrollment Saves Money for Medicare and Improves Care Quality Across a Number of Different Lengths of Stay,” Health Affairs,
March 2013.
November 2014
NHPCO Consulting Services
95
JAMA, November 12, 2014:
Medicare patients with poor-prognosis cancers
who received hospice care had:
– Lower rates of hospitalization
– Fewer ICU admissions
– Fewer invasive procedures
– Significantly lower health care costs
Source: “Use of Hospice Care by Medicare Patients Associated with Lower Rate of Hospitalization, ICU Admission, Invasive Procedures and Costs,” press release from JAMA,
November 11, 2014.
November 2014
NHPCO Consulting Services
96
Upstream Care Types
• Advanced illness management (AIM)
programs
• Community based palliative care
• Post-acute transitional care
• Pre-hospice programs
November 2014
NHPCO Consulting Services
97
Upstream Partners for Hospices in
Washington and Oregon
Seeking those at risk for health expenses:
• Hospitals and health systems (at risk under
exchanges and all-payer systems)
• ACOs in your service area
• Medicare Advantage plans
• Commercial Insurers
• Large self-insured employers (including hospitals)
• Insurers
November 2014
NHPCO Consulting Services
98
How likely is the following by 2019?
98%
Your hospital will be partnering with
community organizations to support
population health management
initiatives
76%
93%
Formal mechanisms will be in place
in your service area to ensure
seamless coordination across the
care continuum
51%
0%
Very Likely
Somewhat Likely
22%
20%
42%
40%
Somewhat Unlikely
60%
80%
100%
Very Unlikely
Source: “Futurescan 2014: Healthcare Trends and Implications 2014-2019,” Society for Healthcare Strategy & Market Development and the American College of
Healthcare Executives, 2014.
November 2014
NHPCO Consulting Services
99
How likely is the following by 2019?
94%
Your hospital or health system will
enter into a partnership or
affiliation with another provider or
payor organization to expand
services or realize efficiencies
53%
0%
Very Likely
Somewhat Likely
20%
41%
40%
Somewhat Unlikely
60%
80%
100%
Very Unlikely
Source: “Futurescan 2014: Healthcare Trends and Implications 2014-2019,” Society for Healthcare Strategy & Market Development and the American College of
Healthcare Executives, 2014.
November 2014
NHPCO Consulting Services
100
How likely is the following by 2019?
96%
Your hospital's strategic plan
will have a goal of reducing
unnecessary admissions
74%
0%
Very Likely
Somewhat Likely
20%
40%
Somewhat Unlikely
22%
60%
80%
100%
Very Unlikely
Source: “Futurescan 2014: Healthcare Trends and Implications 2014-2019,” Society for Healthcare Strategy & Market Development and the American College of
Healthcare Executives, 2014.
November 2014
NHPCO Consulting Services
101
Making the Case to Your Partners: Benefits
of Upstream Palliative Care/Patient
Management
• Patients have better quality of life
• Patients are more likely to use hospice, less
likely to use expensive hospital care
• Patients cost less to care for (when
appropriately selected)
• They may even live longer
Sources: Jennifer Temel, MD, et al., “Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer,” NEJM, August 19, 2010; K. Eric De Jonge, MD,
“Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” JAGS, October 2014.
November 2014
NHPCO Consulting Services
102
Business Planning for Upstream
Programs
1. What population will you serve?
2. How will you manage your patients?
– What clinical model will you use?
– What administrative support will you need?
3. How will you be paid?
– Who are your business partners and payers?
– What are their needs? How can you help them?
4. What will you measure?
– What measures will you track before and after the
program?
November 2014
NHPCO Consulting Services
103
#1 What Population Will You
Serve?
November 2014
NHPCO Consulting Services
104
High Cost Population Is Not All at End
of Life
High-Cost Population
18.2 Million People
High-Cost End-of-Life
Population
2 Million People
Low-Cost End-of-Life
Population
0.5 Million People
Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (IOM), The National Academies Press, Washington,
DC, 2014, Appendix E, p.27.
November 2014
NHPCO Consulting Services
105
High Cost Population Not All Old
Total Population, by Age
High-Cost Population, by
Age
Age
65+
14%
Age
65+
40%
Age
<65
86%
Age
<65
60%
Source: Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine (IOM), The National Academies Press, Washington,
DC, 2014, Appendix E, p.27.
November 2014
NHPCO Consulting Services
106
The Top 5% of Patients Account for
50% of All Healthcare Spending
Percentile Ranked by Health Care Expenditures, 2012
97.3%
100%
86.7%
80%
66.0%
60%
50.0%
40%
22.7%
20%
0%
Top 1%
Top 5%
Top 10%
Top 25%
Top 50%
Source: Steven B. Cohen, Ph.D., “The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2012,” Statistical Brief #455,
AHRQ, October 2014.
November 2014
NHPCO Consulting Services
107
Functional Limitations Greatly Increase
Likelihood of High Expenditures per Patient
Relative Risk of Being in Top 5% of Health Care Spenders
7.7
6.6
6.1
4.3
3.6
1.8
1
0.8
0.8
0.2
Everyone
No
Chronic Functional 1+ Chronic 3+ Chronic Chronic + ADL/IADL ADL/IADL + ADLIADL +
Limitation, illness only limitation
Functional
Chronic 3 Chronic
no chronic
only
limitation
illness
Source: Lewin Group Analysis of 2006 Medical Expenditures Panel Survey, from “Individuals Living in the Community with Chronic Conditions and Functional Limitations,”
report to HHS, January 2010.
108
Ways to Identify the Target Population
• Computer algorithms analyzing patient
records within an insurer database
• Documentation of functional limitations and
chronic illness in a health system EHR
• Routine documentation of answers to the
“surprise” question: “Would you be surprised
if the patient died in the next 12 to 24
months?”
• Physician referral
November 2014
NHPCO Consulting Services
109
Top Five Most Costly Medical
Conditions
1.
2.
3.
4.
5.
Heart disease
Trauma-related disorders
Cancer
Mental disorders
COPD/asthma
Source: Steven B. Cohen, Ph.D., “The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2012,” Statistical Brief #455,
AHRQ, October 2014.
November 2014
NHPCO Consulting Services
110
Clearly Define Your Target Population
• Biggest savings will accrue only if you get the
population right– cost differences are highest
only among the sickest and frailest
• If healthier, lower-risk population is included,
costs can easily outweigh the benefits of
intensive management
November 2014
NHPCO Consulting Services
111
Start Simply, Start Small
• Begin with the low-hanging fruit: Start with
your best program initiative, that promises the
greatest savings with a limited population
• Grow over time: Expand later, after success is
demonstrated
November 2014
NHPCO Consulting Services
112
#2 How Will You Manage Your
Patients?
November 2014
NHPCO Consulting Services
113
Target Population = High Risk Patients
Patients May Have
•
•
•
•
Upstream Care May Involve
Functional limitations
Multiple chronic conditions
Dementia
Serious (life threatening)
illness
• Uncontrolled symptoms
• Recent discharge from
hospital
• Caregiver breakdown
November 2014
• Home safety assessment
• Patient and family
education
• Medication reconciliation
• Diet counseling
• What to do in crisis
• Planning – Care goals
• Visits
• Telephonic support
NHPCO Consulting Services
114
Formal Mechanisms Support Care
Coordination
• Documented handoffs when patient
transfers to another care setting
• Integrated health information portals
• Patient navigators and case managers
• Strong social support care
• Telephonic and urgent care support
November 2014
NHPCO Consulting Services
115
Ensure Your Savings Will Outweigh Your Costs of
Caring for This Population
• Care coordination can be very expensive
– North Shore-Long Island Jewish Health System reports that new
admits to its care coordination program (Care Solution) cost $400 per
member per month
• 2015 Medicare physician fee schedule permits $40.39 per
month per qualifying patient for care coordination
management (codes 99487-99489)
• Most experienced providers suggest starting small to make
sure volume and costs don’t overwhelm the fledgling program
Sources: Kristofer Smith, MD, “Working within Value-Based Contracts to Support Community-Based Palliative Care, presentation to CAPC, September 24, 2014; Donna
Marbury, “2015 Medicare fee schedule offers new care coordination, telehealth codes,” Medical Economics, November 3, 2014.
November 2014
NHPCO Consulting Services
116
Plan for the Fact that High Savings Are
Reserved for Highest-Risk Patients
Medicare Costs by Frailty Category
$76,840
$80,000
$60,000
$56,589
$42,223 $43,353
Managed
$40,000
Control
$22,611
$20,000
$19,146
$0
Lowest frailty
Moderate frailty
Highest frailty
Sources K. Eric De Jonge, MD, “Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders,” JAGS, October 2014.
November 2014
NHPCO Consulting Services
117
#3 How Will You Be Paid?
(Who Will Your Business Partners Be?)
November 2014
NHPCO Consulting Services
118
Financing Upstream Services
(In Order of Level of Support)
•
•
•
•
Full support from partnering health system
Per visit payment
Case rate payment
Palliative care billing for allowed clinical services
(only partially offsets cost)
• Risk-based payments (per member per month)
• Shared savings (as with an MSSP ACO)
November 2014
NHPCO Consulting Services
119
Types of Risk-based Contracts
Type
Description
Pay for
performance
Provider receives incentive payments for meeting certain quality
or cost efficiency targets (usually both)
Shared savings
Provider may receive a portion of any savings incurred through
cost avoidance relative to a pre-determined budget
Shared risk
Providers shares upside and downside risk with insurer/payer
relative to a pre-set target
Full risk or
capitated
Provider gets all or a portion of the premium
Flat payment per covered person, no matter what the utilization
November 2014
NHPCO Consulting Services
120
High-Impact Target Areas for ACO Initiatives
1.
2.
3.
4.
5.
Prevention and wellness
Chronic disease
Reduced hospitalizations
Care transitions
Multi-specialty care coordination of
complex patients
Source: Accountable Care Guide for Hospice & Palliative Care, Toward Accountable Care Consortium, Raleigh, North Carolina.
November 2014
NHPCO Consulting Services
121
Shared Savings Distributions
AnewCare Collaborative, Tennessee
• Aggregate Performance Year One: $6.9 Million
Savings
• Distribution Plan:
– ACO administration gets $10 pmpm off the top
– Reinvest in infrastructure = 50% of remainder
– Distribution to participants = 50%
• Physicians get 64% of participant share
• Hospitals get 36% of participant share
Source: AnewCare Collaborative, Johnson City, TN, from website anewcare.org, accessed November 2014.
November 2014
NHPCO Consulting Services
122
CMS Hospital Compare Can Help Target Your Efforts
Source: http://www.medicare.gov/hospitalcompare, accessed November 13, 2014.
November 2014
NHPCO Consulting Services
123
#4 How Will You Measure Success?
November 2014
NHPCO Consulting Services
124
Measure and Report Your Success
• Be sure to collect baseline data
– demonstrate savings and quality improvements made
under your management
• Work with your business partners to determine what
measures are most meaningful to them:
–
–
–
–
–
–
–
Hospital admissions/re-admissions
Emergency department utilization
Falls
Patient and family satisfaction
Cost reductions/cost avoidance
Lab, imaging, drug costs
chemotherapy use in last month of life
November 2014
NHPCO Consulting Services
125
Models and Resources
November 2014
NHPCO Consulting Services
126
@HOMe Support, Michigan
• Hospice of Michigan in partnership with
BlueCross BlueShield of Michigan
• 80% of patients ultimately transition to
hospice
• Outcomes:
– 9% decrease in ED use
– 33% decrease in hospital admissions
– 57% decrease in hospital re-admissions
– High patient and family satisfaction scores
Source: “Improving Access to High Quality Hospice Care: What is the Optimal Path?” Melissa Aldrige and Jean Kutner, Health Affairs Blog, September 9, 2014.
November 2014
NHPCO Consulting Services
127
Aetna Compassionate Care Program
For the 1% of Medicare Advantage members
enrolled in the program:
– An 82% hospice election rate
– An 81% decrease in acute hospital days
– An 86% decrease in ICU days
– High member and family satisfaction
– Total cost reduction of $12,000 per enrolled
member
Source: A Palliative Care Toolkit and Resource Guide, CAPC and the National Business Group on Health, 2014.
November 2014
NHPCO Consulting Services
128
Hospice Care of California
• Community based palliative care program serving 6 different riskbearing IPAs in California
• Services include telephonic support from an RN and also visits from
an interdisciplinary team:
– MD
– RN
– Social worker
– Chaplain
• HCC receives a per-visit payment and also a small per member, per
month admin fee
Source: A Palliative Care Toolkit and Resource Guide, CAPC and the National Business Group on Health, 2014.
November 2014
NHPCO Consulting Services
129
Use Available Resources for Planning
an Upstream or Palliative Care Program
• NHPCO
• IPAL: Improving Outpatient Palliative Care (CAPC)
• CSU: The Institute for Palliative Care at The
California State University
• Toward Affordable Care Consortium
www.tac-consortium.org
• IOM – “Dying In America” (September 2014)
November 2014
NHPCO Consulting Services
130
131
Always remember
who we serve ---
132
133
NHPCO members enjoy unlimited access to Regulatory Assistance
95% of questions received a response in < 24 hours in 2014
Feel free to email questions to regulatory@nhpco.org
134
Regulatory/ Compliance Team at NHPCO
Judi Lund Person, MPH
Vice President, Regulatory and Compliance
Jennifer Kennedy, MA, BSN, CHC
Director, Regulatory and Compliance
Email us at: regulatory@nhpco.org
135
135
Resources and References
• ICD-9-CM Official Guidelines for Coding and
Reporting
http://www.amaassn.org/resources/doc/cpt/icd9cm_coding_guidelines_
08-09_sm.pdf
• Hospice Quality Reporting Program
– https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Hospice-QualityReporting/index.html
• Hospice CAHPS Survey
– www.Hospicecahpssurvey.org
136
References
• The Centers for Medicare & Medicaid Services (CMS)
Medicare Hospice Wage Index Final Rule and Medicare
hospice payment rates for fiscal year (FY) 2015
– http://www.ofr.gov/OFRUpload/OFRData/2014-18506_PI.pdf
• Medicare Benefit Policy Manual, Chapter 9, Coverage of
Hospice Services Under Hospital Insurance
• Medicare Hospice Conditions of Participation
• OIG FY 2015 Work Plan
– http://oig.hhs.gov/reports-andpublications/archives/workplan/2015/FY15-Work-Plan.pdf
137